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Inoue H, Ochiai T, Kubo H, Yamamoto Y, Morimura R, Ikoma H, Otsuji E. Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports. World J Clin Cases 2021; 9:3424-3431. [PMID: 34002154 PMCID: PMC8107906 DOI: 10.12998/wjcc.v9.i14.3424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/05/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course. We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis, who safely underwent laparoscopic cholecystectomy (LC) and both demonstrated a good outcome.
CASE SUMMARY Case 1: An 89-year-old female. She underwent abdominal contrast-enhanced computed tomography (CECT) due to abdominal pain and diarrhea. Her gallbladder wall indicated the absence of contrast enhancement, thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC. Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated, she was able to be discharged without any serious complications. Case 2: A 91-year-old female. She made an emergency visit with a chief complaint of abdominal pain. Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall. She was diagnosed with gangrenous cholecystitis and underwent LC. Her gallbladder had swelling and diffuse necrosis. Although her preoperative blood culture was positive, she showed a good outcome following surgery.
CONCLUSION Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery, if an early diagnosis can be made and appropriate treatment can be carried out, then even very elderly individuals may be discharged without major complications.
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Affiliation(s)
- Hiroyuki Inoue
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectual University of Medicine, Kyoto 6028566, Japan
| | - Toshiya Ochiai
- Department of Surgery, North Medical Center Kyoto Prefectural University of Medicine, Kyoto 6292261, Japan
| | - Hidemasa Kubo
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 6028566, Japan
| | - Yusuke Yamamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 6028566, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 6028566, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 6028566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 6028566, Japan
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Nassar AHM, Zanati HE, Ng HJ, Khan KS, Wood C. Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates. Surg Endosc 2021; 36:550-558. [PMID: 33528666 PMCID: PMC8741693 DOI: 10.1007/s00464-021-08316-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 02/02/2023]
Abstract
Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
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Affiliation(s)
- Ahmad H M Nassar
- Department of Surgery, University Hospital Monklands, Airdrie, Lanarkshire, UK. .,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK.
| | - Hisham El Zanati
- Department of Surgery, University Hospital Hairmyres, East Kilbride, Lanarkshire, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Hwei J Ng
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Khurram S Khan
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Colin Wood
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
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El Zanati H, Nassar AHM, Zino S, Katbeh T, Ng HJ, Abdellatif A. Gall Bladder Empyema: Early Cholecystectomy during the Index Admission Improves Outcomes. JSLS 2020; 24:e2020.00015. [PMID: 32425482 PMCID: PMC7208918 DOI: 10.4293/jsls.2020.00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES We aim to evaluate our policy of index admission management of gall bladder empyema and the effect of the timing of surgery on the outcomes. METHODS We analyzed a series of 5400 laparoscopic cholecystectomies. Data were collected prospectively over 26 y. Patients were divided into two groups: group 1, intervention within 72 h, and group 2, intervention after 72 h of admission. We had a policy of intention to treat during the index admission, but delays sometimes occurred because of late referral, a need to optimize patients, availability of theater time, or the biliary surgeon being on leave. The groups were then compared with regard to the duration of surgery, the difficulty grading, complications, hospital stay, and conversion rate. RESULTS A total of 372 patients were included; 160 (43%) operated on within 72 h (group 1) and 212 (57%) after 72 h (group 2). There was no statistically significant difference between the two groups with regard to the operation time, conversion rate, and complications rate. The difference in total hospital stay was, however, statistically significant. CONCLUSION Surgical management of empyema should be offered as soon as possible after admission as with any acute cholecystitis. Surgery carried out after 72 h of admission is only associated with longer hospital stay but no statistically significant differences in other outcome parameters. In the presence of specialist expertise, fitness for surgery should be the determining factor of whether or not to offer surgery to these patients, regardless of the interval since their admission.
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Affiliation(s)
- Hisham El Zanati
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad H M Nassar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Samer Zino
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Tarek Katbeh
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Hwei Jene Ng
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ayman Abdellatif
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
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4
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Onoe S, Maeda A, Takayama Y, Fukami Y, Kaneoka Y. A preoperative predictive scoring system to predict the ability to achieve the critical view of safety during laparoscopic cholecystectomy for acute cholecystitis. HPB (Oxford) 2017; 19:406-410. [PMID: 28117229 DOI: 10.1016/j.hpb.2016.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to develop a preoperative scoring system to predict the ability to achieve the critical view of safety (CVS) in patients undergoing emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). METHODS A retrospective review of patients who underwent LC for AC between 2012 and 2015 was performed. The achievement or failure of creating the CVS was judged by operative records, video recordings, and interviews of the surgeons. Independent preoperative variables associated with failure were determined by multivariate logistic regression analysis and a prediction scoring system created. RESULTS A C-reactive protein (CRP) >5.5 mg/dl, gallstone impaction, and symptom onset to operation >72 h were identified as independently correlated risk factors for the failure to achieve the CVS. A preoperative risk scoring system for the failure to create the CVS (0-5 points) was constructed using these 3 factors: CRP >5.5 mg/dl (2 points), gallstone impaction (1 points), and time from symptom onset to operation >72 h (2 points). When monitoring the frequency of patients who had a failure to create the CVS at each score, the incidence of failure increased as the score increased (P<0.001). CONCLUSIONS Using only three preoperative factors, the proposed scoring system provides an objective evaluation of the likelihood that CVS can be achieved in patients undergoing emergency LC for AC.
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Affiliation(s)
- Shunsuke Onoe
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan.
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | - Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | - Yasuyuki Fukami
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
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Eachempati SR, Cocanour CS, Dultz LA, Phatak UR, Albarado R, Rob Todd S. Acute cholecystitis in the sick patient. Curr Probl Surg 2014; 51:441-66. [PMID: 25497405 DOI: 10.1067/j.cpsurg.2014.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/30/2014] [Indexed: 12/24/2022]
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Ejaz A, Sachs T, He J, Spolverato G, Hirose K, Ahuja N, Wolfgang CL, Makary MA, Weiss M, Pawlik TM. A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample. Surgery 2014; 156:538-47. [PMID: 25017135 DOI: 10.1016/j.surg.2014.03.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. METHODS We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. RESULTS A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). CONCLUSION During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.
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Affiliation(s)
- Aslam Ejaz
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Teviah Sachs
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan ACW, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN. TG13 surgical management of acute cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:89-96. [PMID: 23307007 DOI: 10.1007/s00534-012-0567-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. METHODS AND MATERIALS Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. RESULTS There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. CONCLUSION Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
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Romano O, Romano C, Cerbone D, Sperlongano P, Caserta L, Frega N, Cimmino G, D'Agostino A, Addeo R. Two Case Reports of Biliary Tract Injuries during Laparoscopic Cholecystectomy. ISRN GASTROENTEROLOGY 2011; 2011:868471. [PMID: 21991531 PMCID: PMC3168551 DOI: 10.5402/2011/868471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 01/12/2011] [Indexed: 11/23/2022]
Abstract
Background and Study Aims. Biliary tract injuries (BTI) represent the most serious and potentially life-threatening complication of cholecystectomy occurring also during laparoscopic approaches. Patients and Methods. We describe and discuss two different cases of BTI occurring during laparoscopic cholecystectomy (LC). Results. Two patients developed BTI during LC and one evidenced the complication during the LC itself and was treated during the same LC in real time. The other patient evidenced BTI only after the primary intervention and was successfully reoperated in laparotomy after 10 days from the LC. Conclusions. The factors that predispose to the occurrence of BTI during cholecystectomy and the cautions to be used to prevent BTI are discussed.
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Affiliation(s)
- O Romano
- General Surgery Division, "Cardinale Ascalesi" Hospital, Via egiziaca a Forcella, 80100 Naples, Italy
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Simopoulos C, Botaitis S, Polychronidis A, Trypsianis G, Perente S, Pitiakoudis M. Laparoscopic cholecystectomy in patients with empyematous cholecystitis: an outcome analysis. Indian J Surg 2009; 71:258-64. [PMID: 23133169 DOI: 10.1007/s12262-009-0075-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 04/19/2009] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder. METHODS From May 1992 to July 2007, 315 patients with a clinical diagnosis of acute cholecystitis underwent LC. Operative and histopathology reports were used to identify patients with empyema of the gallbladder, to which retrospective chart reviews were applied. Factors associated with conversion and complications were assessed to determine their predictive power. RESULTS Being male and having high levels of aspartate transaminase (AST), alanine transaminase (ALT), and white blood cells significantly influenced the prediction of empyema. The conversion rate was significantly higher for empyema and acute cholecystitis, but the complication rate did not differ significantly between these conditions. Previous abdominal surgery was an independent risk factor for conversion and complications. Also, temperature >37.5°C, AST >60 IU/l, and ALT >60 IU/l were associated with higher conversion rates. The hospital stay was longer in patients with empyema, while the operation time did not differ between the two groups. CONCLUSION Empyema of the gallbladder can be encountered in patients with presumed acute cholecystitis. Preoperatively differentiating between simple acute cholecystitis and empyema is difficult, if not impossible. The conversion rate is expected to be higher when empyema is approached laparoscopically than for simple acute cholecystitis or symptomatic cholelithiasis.
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Palanivelu C, Jani K, Maheshkumar GS. Single-center experience of laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2007; 17:608-614. [PMID: 17907973 DOI: 10.1089/lap.2006.0192] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The laparoscopic cholecystectomy procedure is considered as the gold standard for the management of benign symptomatic gallbladder diseases. In this paper, we present our experience as a tertiary reference center in the management of this disease. METHODS A total of 9864 laparoscopic cholecystectomies have been performed in our institution since 1991. All patients undergo a routine hematologic work-up, high resolution ultrasonography, and, thereafter, a four-port cholecystectomy by the North American approach. We specifically considered 10 areas of controversy. RESULTS The male:female ratio was 45:55, with the average age being 40.4 years (range, 1 year 4 months to 92 years). Asymptomatic patients were 986 in number and 25% had acute cholecystitis, whereas 2.28% had associated choledocholithiasis. The "fundus first" approach was adopted in 88 patients. Three patients had occult gallbladder cancer, of which 2 were in situ and 1 was of the T1 stage. Nearly one third of the patients had gallstone spillage, primarily owing to the performance of a subtotal cholecystectomy procedure in the setting of acute cholecystitis. However, only 1 patient to date has had a problem directly attributable to gallstone spillage. Nearly 13% of patients had an additional procedure along with a cholecystectomy. The average operating time was 21.5 minutes, whereas the average length of postoperative stay was 1.6 days. CONCLUSIONS The laparoscopic approach is suitable for the management of all forms of benign gallbladder diseases. In addition, it is possible to use the laparoscopic approach for indications hitherto considered relatively contraindicated. In a dedicated center, it is possible to perform a large number of cases with low morbidity and minimal conversion rates.
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Yamashita Y, Takada T, Hirata K. A survey of the timing and approach to the surgical management of patients with acute cholecystitis in Japanese hospitals. ACTA ACUST UNITED AC 2007; 13:409-15. [PMID: 17013715 DOI: 10.1007/s00534-005-1088-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 12/08/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE Despite the fact that there is evidence advocating early laparoscopic cholecystectomy for acute cholecystitis (AC), the practice of this treatment has not been investigated sufficiently. This study was designed to assess the current practice of laparoscopic cholecystectomy for AC among Japanese general surgeons. METHODS A postal questionnaire was sent to the 291 councillors of the Japanese Society of Abdominal Emergency Medicine in order to ascertain their current management of patients with AC. RESULTS The response rate was 72.5%. A policy of early cholecystectomy for AC was adopted by 41.7% of the responding surgeons. However, almost the same percentage of surgeons routinely managed their patients conservatively, and opted for delayed cholecystectomy at a later date. The adoption of laparoscopic cholecystectomy was made by 79.1% of surgeons. Laparoscopic cholecystectomy for patients with AC who had percutaneous transhepatic gallbladder drainage (PTGBD) was adopted by 73.9% of the surgeons. Of the surgeons opting for laparoscopic cholecystectomy, 37.3% performed intraoperative cholangiography laparoscopically for all patients with AC. CONCLUSIONS Although early cholecystectomy for patients with AC was not adopted by the majority of the surgeons who responded, laparoscopic cholecystectomy was a common procedure for early and delayed cholecystectomy. Despite evidence that strongly supports the use of early cholecystectomy, the use of this treatment remains suboptimal in Japan.
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Affiliation(s)
- Yuichi Yamashita
- Second Department of Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
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13
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Yüksel O, Salman B, Yilmaz U, Akyürek N, Tatlicioğlu E. Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval--a prospective study. ACTA ACUST UNITED AC 2007; 13:421-6. [PMID: 17013717 DOI: 10.1007/s00534-005-1095-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Accepted: 12/16/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND/PURPOSE The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. METHODS The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8-12 weeks after medical treatment. RESULTS There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). CONCLUSIONS Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in "cooling down", and additional problems such as choledocholithiasis and biliary pancreatitis.
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Affiliation(s)
- Osman Yüksel
- Gazi University Medical School, Department of General Surgery, Hepato-Pancreato-Biliary Surgery Unit, Beşevler, 06500, Ankara, Turkey
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14
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Yamashita Y, Takada T, Kawarada Y, Nimura Y, Hirota M, Miura F, Mayumi T, Yoshida M, Strasberg S, Pitt HA, de Santibanes E, Belghiti J, Büchler MW, Gouma DJ, Fan ST, Hilvano SC, Lau JWY, Kim SW, Belli G, Windsor JA, Liau KH, Sachakul V. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. ACTA ACUST UNITED AC 2007; 14:91-7. [PMID: 17252302 PMCID: PMC2784499 DOI: 10.1007/s00534-006-1161-x] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 08/06/2006] [Indexed: 12/12/2022]
Abstract
Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.
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Affiliation(s)
- Yuichi Yamashita
- Department of Surgery, Fukuoka University Hospital, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
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15
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Abstract
BACKGROUND Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma. This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions. MATERIALS AND METHODS Review and commentary on pertinent articles in the English language literature are presented. RESULTS Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting. In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard. CONCLUSION As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired. A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application. When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease. Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty. Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair. Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.
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Affiliation(s)
- Frank J Branicki
- Department of Surgery, United Arab Emirates University, Al Ain, United Arab Emirates.
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16
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Jani K, Rajan PS, Sendhilkumar K, Palanivelu C. Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy. J Minim Access Surg 2006; 2:49-58. [PMID: 21170235 PMCID: PMC2997273 DOI: 10.4103/0972-9941.26646] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Accepted: 02/15/2006] [Indexed: 12/22/2022] Open
Abstract
This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.
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Affiliation(s)
- Kalpesh Jani
- Departments of Gem Hospital, 45A, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641045, India
| | - P S Rajan
- Departments of Gem Hospital, 45A, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641045, India
| | - K Sendhilkumar
- Departments of Gem Hospital, 45A, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641045, India
| | - C Palanivelu
- Departments of Gem Hospital, 45A, Pankaja Mill Road, Ramanathapuram, Coimbatore - 641045, India
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17
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Sekimoto M, Imanaka Y, Hirose M, Ishizaki T, Murakami G, Fukata Y, QIP Cholecystectomy Expert Group. Impact of treatment policies on patient outcomes and resource utilization in acute cholecystitis in Japanese hospitals. BMC Health Serv Res 2006; 6:40. [PMID: 16569249 PMCID: PMC1488841 DOI: 10.1186/1472-6963-6-40] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 03/29/2006] [Indexed: 11/13/2022] Open
Abstract
Background Although currently available evidence predominantly recommends early laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis, this strategy has not been widely adopted in Japan. Herein, we describe a hospital-based study of patients with acute cholecystitis in 9 Japanese teaching hospitals in order to evaluate the impact of different institutional strategies in treating acute cholecystitis on overall patient outcomes and medical resource utilization. Methods From an administrative database and chart review, we identified 228 patients diagnosed with acute cholecystitis who underwent cholecystectomy between April 2001 and June 2003. In order to examine the relationship between hospitals' propensity to perform LC and patient outcomes and/or medical resource utilization, we divided the hospitals into three groups according to the observed to expected ratio of performing LC (LC propensity), and compared the postoperative complication rate, length of hospitalization (LOS), and medical charges. Results No hospital adopted the policy of early surgery, and the mean overall LOS among the subjects was 30.9 days. The use of laparoscopic surgery varied widely across the hospitals; the adjusted rates of LC to total cholecystectomies ranged from 9.5% to 77%. Although intra-operative complication rate was significantly higher among patients whom LC was initially attempted when compared to those whom OC was initially attempted (9.7% vs. 0%), there was no significant association between LC propensity and postoperative complication rates. Although the postoperative time to oral intake and postoperative LOS was significantly shorter in hospitals with high use of LC, the overall LOS did not differ among hospital groups with different LC propensities. Medical charges were not associated with LC propensity. Conclusion Under the prevailing policy of delayed surgery, in terms of the postoperative complication rate and medical resource utilization, our study did not show the superiority of LC in treating acute cholecystitis patients. The timing of surgery and discharge was mainly determined by the institutional policy in Japan, rather than by the clinical course of the patient; however, considering the substantially less postoperative pain and shorter recovery time of LC compared to OC, LC should be actively applied for the treatment of acute cholecystitis. If the policy of early surgery were universally applied, the advantage of LC over OC may be more clearly demonstrated.
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Affiliation(s)
- Miho Sekimoto
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - Masahiro Hirose
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - Tatsuro Ishizaki
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - Genki Murakami
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - Yushi Fukata
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
| | - QIP Cholecystectomy Expert Group
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606–8501, Japan
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18
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Dominguez EP, Giammar D, Baumert J, Ruiz O. A Prospective Study of Bile Leaks after Laparoscopic Cholecystectomy for Acute Cholecystitis. Am Surg 2006. [DOI: 10.1177/000313480607200313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgeons are increasingly performing laparoscopic cholecystectomy in the setting of acute cholecystitis. The acutely inflamed gallbladder poses a more technically demanding dissection with potential for an increase in bile leak rates. Clinical and subclinical bile leak rates after laparoscopic and open cholecystectomy in the elective setting are known. This study prospectively evaluates the rate of clinical and subclinical bile leaks after laparoscopic cholecystectomy in the setting of acute cholecystitis. One hundred patients underwent laparoscopic cholecystectomy for acute cholecystitis, as determined intraoperatively and by history, ultrasound, fever, or leukocytosis. On postoperative Day 1, the patients underwent cholescintigraphy (PIPIDA scan) analyzed by a board-certified radiologist for evidence of bile leaks. Postoperative cholescintigraphy revealed eight scans positive for bile leaks. Regardless of scan result, no patient experienced a clinically symptomatic bile leak. Laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis with acceptable clinical and subclinical bile leak rates.
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Affiliation(s)
- Edward P. Dominguez
- From the Riverside Methodist Hospital, Department of Surgery, Columbus, Ohio
| | - Dave Giammar
- From the Riverside Methodist Hospital, Department of Surgery, Columbus, Ohio
| | - John Baumert
- From the Riverside Methodist Hospital, Department of Surgery, Columbus, Ohio
| | - Oscar Ruiz
- From the Riverside Methodist Hospital, Department of Surgery, Columbus, Ohio
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19
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Johansson M, Thune A, Nelvin L, Stiernstam M, Westman B, Lundell L. Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. Br J Surg 2005; 92:44-9. [PMID: 15584058 DOI: 10.1002/bjs.4836] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. METHODS Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care. RESULTS The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011). CONCLUSION Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.
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Affiliation(s)
- M Johansson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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20
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Giger U, Michel JM, Vonlanthen R, Becker K, Kocher T, Krähenbühl L. Laparoscopic cholecystectomy in acute cholecystitis: indication, technique, risk and outcome. Langenbecks Arch Surg 2004; 390:373-80. [PMID: 15316783 DOI: 10.1007/s00423-004-0509-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Accepted: 06/14/2004] [Indexed: 01/12/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic cholelithiasis. However, the laparoscopic approach has remained controversial for patients with acute cholecystitis (AC) because of technical difficulties that, compared with open cholecystectomy (OC), might lead to higher complication rates, particularly common bile duct (CBD) injuries and infection. METHODS We reviewed recent clinical findings on feasibility, safety and potential benefits of LC in patients with AC. An electronic search using the PubMed and MEDLINE databases was performed using the terms laparoscopic cholecystectomy, open cholecystectomy and acute cholecystitis. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed. CONCLUSIONS The early laparoscopic approach has been shown to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calot's triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to OC remains an important treatment option to secure patient safety in such difficult conditions. The question of whether intraoperative cholangiography (IOC) should be used routinely or only selectively has never been resolved. Proponents for each side have put forward compelling arguments.
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Affiliation(s)
- U Giger
- Department of Surgery, Hôpital Cantonal Fribourg, 1700, Fribourg, Switzerland
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21
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Cameron IC, Chadwick C, Phillips J, Johnson AG. Management of acute cholecystitis in UK hospitals: time for a change. Postgrad Med J 2004; 80:292-4. [PMID: 15138321 PMCID: PMC1743001 DOI: 10.1136/pgmj.2002.004085] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice in the management of acute cholecystitis in the UK. A postal questionnaire was sent to 440 consultant general surgeons to ascertain their current management of patients with acute cholecystitis. Replies were received from 308 consultants who were involved in treating patients with acute cholecystitis of whom 18 transferred these patients on to another team for further management the day after admission. Thirty two consultants (11%) routinely treated patients by early cholecystectomy, with limiting factors stated to be the availability of surgical staff, theatre space, and radiological investigations. The remaining consultants (n = 258) routinely manage their patients conservatively with intravenous antibiotics and allow the inflammation to resolve before undertaking cholecystectomy at a later date. Indications for undertaking early cholecystectomy during the first admission by this latter group included the presence of spreading peritonitis due to bile leak, empyema, and unexpected space on theatre list. The commonest method for both elective and early cholecystectomy is laparoscopic, but the percentage of consultants using an open method rises from 8% in the elective situation to 47% for urgent early cholecystectomy. Despite evidence which strongly advocates early cholecystectomy, this practice is routinely carried out by only 11% of consultants in the UK at present.
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Affiliation(s)
- I C Cameron
- University Surgical Unit, Royal Hallamshire Hospital, Sheffield, UK.
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22
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Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004; 187:475-81. [PMID: 15041494 DOI: 10.1016/j.amjsurg.2003.12.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Revised: 08/11/2003] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS Relevant articles in English were identified from the Medline database, and reviewed. RESULTS The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.
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Affiliation(s)
- Matthew S Metcalfe
- Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Rd., Woodville, SA 5011, Australia
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23
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Bender JS, Duncan MD, Freeswick PD, Harmon JW, Magnuson TH. Increased laparoscopic experience does not lead to improved results with acute cholecystitis. Am J Surg 2002; 184:591-4; discussion 594-5. [PMID: 12488180 DOI: 10.1016/s0002-9610(02)01089-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As laparoscopic experience increases, ever more challenging cases are attempted. Enlarged surgeon experience, along with better technology, has been lauded as improving outcomes. The purpose of this study is to see if this applies to the management of acute cholecystitis. METHODS We reviewed our experience over a 7 and a half year period. Information was obtained from a prospectively maintained computer database containing patient presentation, demographics, workup, laboratory values, and outcomes. Diagnosis of gangrene was based on pathologic examination of the specimen. RESULTS There were 305 patients admitted to our institution with acute cholecystitis. Group I (n = 111) was admitted during the first half of the study and group II (n = 194) during the second half. Demographics were similar in the two groups. While slightly more patients were attempted laparoscopically in group II (90% versus 82%), conversion rates were virtually identical (27.1% versus 27.5%). There was a trend toward improved results with group II versus group I in mortality (3% versus 4%) and morbidity (14% versus 21%; P = not significant). Deaths were divided between sepsis and cardiac events. Gangrenous cholecystitis was less frequent in group II patients (29% versus 40%; P = 0.06). Analysis of gangrene versus non-gangrene patients within each group showed that conversion rates remained twice as high (40% versus 20%; P < 0.05) in those with gangrene. Interestingly, gangrene had no effect on morbidity or mortality. CONCLUSIONS Morbidity and mortality for acute cholecystitis remain relatively high. These seem to be determined by the degree of acute and chronic illness present at the time of diagnosis. As conversion rates remain unchanged, increased surgeon experience and further advances in laparoscopic technology are unlikely to dramatically affect results. Efforts to improve outcomes for this common disease should therefore focus on better and earlier identification of patients for operation.
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Affiliation(s)
- Jeffrey S Bender
- Department of Surgery, Johns Hopkins Bayview Medical Center and The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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24
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Al-Mulhim AS, Al-Mulhim FM, Al-Suwaiygh AA. The role of laparoscopic cholecystectomy in the management of acute cholecystitis in patients with sickle cell disease. Am J Surg 2002; 183:668-72. [PMID: 12095599 DOI: 10.1016/s0002-9610(02)00872-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND As emergency surgery in sickle cell disease patients is associated with high morbidity, the aim of the study was to assess the safety of laparoscopic cholecystectomy in the acute state for these patients. METHODS Over a 5-year period, April 1994 till December 1998, 35 sickle cell patients with acute cholecystitis had laparoscopic cholecystectomy within the first 5 days of presentation. A retrospective study of these was undertaken. RESULTS Thirty-five patients were diagnosed as having acute cholecystitis with sickle cell disease. There were 26 female and 9 male patients; 5 patients needed preoperative and 1 patient needed postoperative endoscopic retrograde cholangiopancreatography. Twenty-seven patients needed simple transfusion and 8 needed partial exchange; conversion was necessary in two cases (5.7%). The mean hospital stay was 5.3 days and the complication rate was 17.5%. CONCLUSIONS Because of the lack of significant complications, we believe that laparoscopic cholecystectomy for acute cholecystitis is safe and recommended in experienced hands with adequate preoperative preparation for patients with sickle cell disease.
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25
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Brasesco OE, Rosin D, Rosenthal RJ. Laparoscopic surgery of the liver and biliary tract. J Laparoendosc Adv Surg Tech A 2002; 12:91-100. [PMID: 12019579 DOI: 10.1089/10926420252939592] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.
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26
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Abstract
Although elective laparoscopic cholecystectomy is today's gold standard for the treatment of symptomatic cholelithiasis, its safety and effectiveness for acute cholecystitis remain controversial. The authors present a retrospective study comparing laparoscopic cholecystectomy in the acute versus the elective setting. A total of 605 patients were treated surgically for gallstone disease between August 1991 and January 1999. A total of 269 patients (44.5%) underwent surgery for acute cholecystitis as soon as possible after diagnosis, and elective cholecystectomy was performed on 336 patients (55.5%) for symptomatic gallstones. Initial open cholecystectomy was performed on 52 (19.3%) of the acute patients and 16 (4.8%) of the elective patients. Laparoscopic cholecystectomy was attempted on 217 of the acute patients (80.7%), with 11 cases (5.1%) converted to open cholecystectomy, and on 320 (95.2%) of the elective patients, with 6 cases (1.9%) converted to open cholecystectomy. The mean (+/-SD) operative time for the acute and elective patients was 105 (+/-38) and 85 (+/-21) minutes, respectively (P < 0.05). There was no perioperative mortality in either laparoscopic group. Surgical complications related to laparoscopic cholecystectomy in the acute and elective groups occurred in six (2.9%) and eight (2.5%) cases, respectively (P = NS). The current study shows that early laparoscopic cholecystectomy for acute cholecystitis is safe and efficient. Low conversion rates can be maintained with strict guidelines for appropriate patient selection, adequate experience, and proper laparoscopic technique.
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27
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28
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Chen HH, Wexner SD, Iroatulam AJ, Pikarsky AJ, Alabaz O, Nogueras JJ, Nessim A, Weiss EG. Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum 2000; 43:61-5. [PMID: 10813125 DOI: 10.1007/bf02237245] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to compare the length of postoperative ileus in patients undergoing colectomy by either laparotomy or laparoscopy. METHODS A total of 166 patients were studied. These patients were divided into two groups: Group 1, in which colectomy was done laparoscopically, and Group 2, consisting of patients undergoing laparotomy. Both groups contained 83 patients who were matched for disease severity, indications for surgery, and procedure. Indications for surgery included sigmoid diverticulitis in 12 (14 percent) patients, polyps in 22 (27 percent), Crohn's disease in 21 (25 percent), colorectal cancer in 11 (13 percent), stoma reversal in 8 (10 percent), rectal prolapse in 3 (4 percent), and other indications in 6 (7 percent) in each group. Operations were colectomy with anastomosis (42 ileocolic, 26 colorectal, 6 colocolic, 4 ileorectal, and 2 ileal J pouch) or without anastomosis (3 abdominoperineal resections) performed by the same surgeons during the same time period January 1993 to October 1996). The nasogastric tube was removed from all patients immediately after surgery in both groups. All patients received a clear liquid diet on the first postoperative day, followed by a regular diet as tolerated. The nasogastric tube was reinserted if two or more episodes of emesis of more than 200 ml occurred in the absence of bowel movement. Patients were discharged from the hospital when tolerating a regular diet without evidence of ileus. Statistical analysis was performed using unpaired t-test and Fisher's exact probability test. RESULTS The male-to-female ratio was 38 to 45 in both groups. A total of 10 (12 percent) and 23 (28 percent) patients in Group 1 and Group 2 had emesis (P = 0.02), and the rate of nasogastric tube reinsertion was 5 (6 percent) and 13 (16 percent), respectively (P > 0.05). There were significant differences between Groups 1 and 2 relative to the lengths of ileus (3.5 +/- 1.3 vs. 5.4 +/- 1.7 days, respectively; P < 0.001), hospitalization (6.6 +/- 3.3 vs. 8.1 +/- 2.5 days, respectively; P < 0.002), and operative time (170 +/- 60 vs. 114 +/- 46 minutes, respectively; P < 0.001). The morbidity rate was 16 (19.2 percent) and 18 (21.6 percent) in the laparoscopy and laparotomy groups, respectively. CONCLUSIONS Although early oral intake is safe and can be tolerated by 84 percent of patients after colectomy by laparotomy, laparoscopic colectomy reduced the lengths of both postoperative ileus and hospitalization.
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Affiliation(s)
- H H Chen
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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29
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Riedel P. THE EARLY OPERATION OF ACUTE SEVERE CHOLECYSTITIS. ANZ J Surg 1999. [DOI: 10.1046/j.1440-1622.1999.1719b.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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30
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Scheele S, Miller DA, Hardy KJ. The early operation for acute severe cholecystitis: the Riedel paper; an introduction and translation. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:871-7. [PMID: 10613287 DOI: 10.1046/j.1440-1622.1999.1719a.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND For acute cholecystitis in the latter 19th century and early 20th century, the diagnosis was difficult and the management not defined. METHODS AND RESULTS Bernhard Riedel of Jena in Germany documented his patients, analysed his results, and described his method of cholecystectomy. CONCLUSIONS Riedel advocated early operation for acute cholecystitis when the conditions were favourable, as for acute appendicitis. He stressed the importance of good lighting, an experienced surgeon and trained assistants. He advocated conservative treatment for minor cholecystitis (biliary colic) until the diagnosis was certain, followed by elective cholecystectomy to reduce the risk of subsequent acute cholecystitis or bile duct stones. Caution was advised when analysing previous statistics, to ensure appropriate patient comparison.
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Affiliation(s)
- S Scheele
- University of Erlangen-Nürnberg, Department of Plastic Surgery, Erlangen, Germany
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31
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Araujo-Teixeira JP, Rocha-Reis J, Costa-Cabral A, Barros H, Saraiva AC, Araujo-Teixeira AM. [Laparoscopy or laparotomy in acute cholecystitis (200 cases). Comparison of the results and factors predictive of conversion]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1999; 124:529-35. [PMID: 10615781 DOI: 10.1016/s0001-4001(00)88276-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
STUDY AIM The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy. PATIENTS AND METHODS From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disresponsibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis. RESULTS Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 degrees C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p = 0.0002) and hospital stay longer (12 +/- 10 days, versus 5 +/- 3) in the laparotomy group (p = 0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis: plastron, fever above 38 degrees C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of "Klebsiella" in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors. CONCLUSION Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependent on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.
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Affiliation(s)
- J P Araujo-Teixeira
- Service de chirurgie II, Hôpital S-Joao, Faculté de médecine de Porto, Portugal
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Molloy M, Sorrell MJ, Bower RH, Hasselgren PO, Dalton BJ. Patterns of morbidity and resource consumption associated with laparoscopic cholecystectomy in a VA medical center. J Surg Res 1999; 81:15-20. [PMID: 9889051 DOI: 10.1006/jsre.1998.5493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The generally low incidence of morbidity and reduced rate of health care resource consumption commonly associated with laparoscopic cholecystectomy (LC) have been established from studies of patient populations which are distinct from that served by the Department of Veterans Affairs (VA) health care system. We sought to assess the outcomes of this procedure when performed on VA beneficiaries. MATERIALS AND METHODS Demographic and perioperative data for all patients undergoing attempted LC in our facility were recorded in a prospective database beginning 1 January 1993. The information in this registry was analyzed to determine the demographics of the treated population, the spectrum of biliary tract disease encountered, and patterns of morbidity and resource consumption. RESULTS LC was attempted in 141 cases. Median patient age was 62 years. The indication for surgery was either acute cholecystitis or biliary pancreatitis in 63 cases (45%). Thirteen patients (9%) developed major complications. These patients were significantly older (mean age 68 vs 59 years) than patients whose course was uncomplicated. Twenty-seven cases (19%) required conversion to an open procedure, most commonly for acute cholecystitis. Progressive cholecystitis was associated with a conversion rate of 64%. Both conversion and the development of a major complication produced significant increases in length of stay. CONCLUSIONS The population undergoing attempted LC in the VA system is characterized by relatively advanced age and high incidences of comorbid illness and complicated biliary tract disease. These attributes increase the frequency of major morbidity and of conversion to open cholecystectomy, which in turn increase resource consumption. Comparisons between the outcomes of attempted LC in VA centers and "benchmark" results obtained in other settings should be controlled for these factors.
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Affiliation(s)
- M Molloy
- Veterans Affairs Medical Center, Cincinnati, Ohio, 45220, USA
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33
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Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998; 351:321-5. [PMID: 9652612 DOI: 10.1016/s0140-6736(97)08447-x] [Citation(s) in RCA: 253] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. METHODS 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). FINDINGS The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). INTERPRETATION Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.
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Affiliation(s)
- T Kiviluoto
- Second Department of Surgery, Helsinki University Central Hospital, Finland
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34
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Abstract
The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.
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Affiliation(s)
- K D Lillemoe
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287-4603, USA
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Escalante Hurtado JR, Goldenberg S, Novo NF, Juliano Y, Escalante RD. Estudo anatômico das vias bilíferas extra-hepáticas no suíno. Comparação entre a dissecção convencional e por videolaparoscopia. Acta Cir Bras 1997. [DOI: 10.1590/s0102-86501997000300012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Estudou-se no presente trabalho, através de dissecção de peças anatômicas constituidas de fígado e duodeno, a morfologia das vias bilíferas do suíno. Os animais foram separados em dois grupos iguais, sendo que o primeiro foi submetido a colecistectomia videolaparoscópica. O segundo grupo era constituído de suínos abatidos para consumo. Os animais do grupo da colecistectomia videolaparoscópica eram observados por um período curto de pós-operatório e depois abatidos para retirada de peças anatômicas, tendo sido realizado o estudo das vias bilíferas extra-hepáticas. No segundo grupo eram as peças retiradas após o abate dos animais, estas eram dissecadas, coradas com tinta guache e posteriormente submetidas a estudo radiológico com a injeção de Bário. Os dados obtidos foram analizados utilizando-se o teste de FISHER. Verificou-se que o ductus choledocus é constituído pela união do ductus cysticus e ductus hepaticus na grande maioria dos casos (84.3%). Verificou-se também que o ductus hepaticus é formado, em grande número dos casos, pela confluência do ductus principalis sinister e ductus principalis dexter. Os resultados encontrados permitem concluir que não existem diferenças significantes, no que se refere à conformação das vias bilíferas extra-hepáticas em ambos os grupos.
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Larach SW, Patankar SK, Ferrara A, Williamson PR, Perozo SE, Lord AS. Complications of laparoscopic colorectal surgery. Analysis and comparison of early vs. latter experience. Dis Colon Rectum 1997; 40:592-6. [PMID: 9152190 DOI: 10.1007/bf02055385] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to test if the techniques learned during our early learning experience have proved to be effective in reducing the complications specifically related to the laparoscopic technique of colorectal surgery. METHODS From October 1991 until July 1996, 195 laparoscopic operations were performed on the colon and the rectum. These data were divided into "early" and "latter" groups. The conversion reasons and early and late postoperative complications were analyzed and compared. RESULTS Incidence of conversions required because of iatrogenic injuries showed a decline from 7.3 percent in the early group to 1.4 percent in the latter group. Sixty-six postoperative complications were observed in 59 (30.3 percent) patients. Complications specifically related to the technique of laparoscopic surgery occurred in nine (4.6 percent) patients. These were postoperative bleeding in three patients, port site hernias in five patients, and left ureteric stricture in one patient. Eight (6.5 percent) of these complications occurred in the early group, whereas one (1.4 percent) occurred in the latter group. Analyzing the conversions caused by intraoperative iatrogenic injuries and the specific postoperative complications together reveals that the incidence of 13.8 percent (17/123) in the early group has been reduced significantly to 2.8 percent (2/72) in the latter group. CONCLUSIONS On the basis of our experience, we have identified techniques, which are discussed in detail, to make laparoscopic colorectal surgery safe. Strict adherence to these techniques has significantly reduced the incidence of complications, specifically those related to the laparoscopic technique.
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Affiliation(s)
- S W Larach
- Orlando Regional Medical Center, Florida, USA
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37
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38
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Taylor EW, Guirguis LM, Johna SD. Laparoscopic cholecystectomy in histologically confirmed acute cholecystitis. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1996; 6:227-32. [PMID: 8877740 DOI: 10.1089/lps.1996.6.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Forty-four patients with histologically confirmed acute cholecystitis (AC) underwent attempted laparoscopic cholecystectomy (LC) from August 1990 to February 1994 and were retrospectively reviewed. During this time frame, LC was attempted in all patients with AC. Twelve of the patients were scheduled for elective LC as they were not thought to have AC preoperatively. Interestingly, eight of these unsuspected cases of acute cholecystitis had both a normal preoperative white blood cell count and were afebrile. The other 32 patients had a clinical presentation consistent with AC. The only diagnostic finding common to all cases of AC was abdominal pain and tenderness. In addition to AC, five patients also had gallstone pancreatitis, and three others were found to have concomitant choledocholithiasis. Fourteen patients required intraoperative conversion to open cholecystectomy for a laparoscopic success rate of 68%. The most common reason for conversion was difficulty in the dissection or unclear anatomy caused by dense adhesions. LC is an appropriate surgical treatment of AC, provided the surgeon abandons the laparoscopic approach if unable to safely proceed. Diagnostic and admission criteria for AC that requires elevated white blood cell count and/or fever may need revision.
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Affiliation(s)
- E W Taylor
- Department of Surgery, Kern Medical Center, Bakersfield, California, USA
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39
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Al-Saigh AA, Fadl-Elahi FA, Maqboolfazili F. Analysis of laparascopic cholecystectomies in 606 patients: Experience at King Fahad Hospital, Medina. Ann Saudi Med 1996; 16:392-4. [PMID: 17372467 DOI: 10.5144/0256-4947.1996.392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This is a retrospective study of 606 patients who underwent laparoscopic cholecystectomy at King Fahad Hospital, Medina, Saudi Arabia. The majority of them, 488 (80.5%), were females. Fifty (8.3%) patients presented with acute cholecystitis and 556 (91.7%) were chronic cases. Common bile duct stones were detected in 22 (3.6%) patients. Laparoscopic cholecystectomy was successful in 539 (89%) patients and converted to open cholecystectomy in 67 (11%) patients due to a variety of reasons. The mean operative time was 65.9 minutes. Most of the patients (64.7%) were discharged within 72 hours. There were no deaths in this series. The overall complication rate was 5.6% and the incidence of major ductal injury was 0.8%.
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Affiliation(s)
- A A Al-Saigh
- Department of General Surgery, King Fahad Hospital, Medina, Saudi Arabia
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40
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Wiebke EA, Pruitt AL, Howard TJ, Jacobson LE, Broadie TA, Goulet RJ, Canal DF. Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors. Surg Endosc 1996; 10:742-5. [PMID: 8662431 DOI: 10.1007/bf00193048] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Identifying patients who are at risk for conversion from laparoscopic (LC) to open cholecystectomy (OC) has proven to be difficult. The purpose of this review was to identify factors that may be predictive of cases which will require conversion to laparotomy for completion of cholecystectomy. METHODS We reviewed 581 LCs initiated between July 1990 and August 1993 at a university medical center and recorded reasons for conversion to OC. Statistical analysis was then performed to identify factors predictive of increased risk for conversion. RESULTS Of the 581 LC initiated, 45 (8%) required OC for completion. Reasons for conversion included technical and mandatory reasons and equipment failure. By multivariate analysis, statistically significant risk factors for conversion included increasing age, acute cholecystitis, a history of previous upper abdominal surgery, and being a patient at the Veterans Affairs Medical Center (VAMC). Factors not increasing risk of conversion included gender and operating surgeon. CONCLUSIONS We conclude that no factor alone can reliably predict unsuccessful LC, but that combinations of increasing age, acute cholecystitis, previous upper abdominal surgery, and VAMC patient result in high conversion rates. Patients with the defined risk factors may be counseled on the increased likelihood of conversion. However, LC can be safely initiated for gallbladder removal with no excess morbidity or mortality should conversion be required.
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Affiliation(s)
- E A Wiebke
- Department of Surgery, Indiana University Medical Center, 545 Emerson Hall, EM 242, Indianapolis, IN 46202, USA
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41
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Maruszynski M, Pojda Z. Interleukin 6 (IL-6) levels in the monitoring of surgical trauma. A comparison of serum IL-6 concentrations in patients treated by cholecystectomy via laparotomy or laparoscopy. Surg Endosc 1995; 9:882-5. [PMID: 8525439 DOI: 10.1007/bf00768883] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Interleukin 6 (IL-6) is involved in the processes of inflammation and tissue repair. We have been looking for the correlation between IL-6 concentration in patient's serum and the other factors related to the gravity of surgical trauma. Out of 25 patients with acute cholecystitis, 11 were randomly selected for laparoscopic cholecystectomy and the other 14 for open (laparotomic) cholecystectomy. The diagnostic and prognostic factors, age, and duration of disease did not differ significantly in either group. IL-6 serum levels were monitored by using commercially available ELISA tests throughout 72 h following the surgery. In patients who underwent laparoscopy, average IL-6 serum levels were significantly (up to fourfold) lower than in their laparotomy-treated counterparts, and the monitoring of IL-6 serum levels seems to be useful in the evaluation of the extent of trauma caused by surgery.
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Affiliation(s)
- M Maruszynski
- Department of Surgery, Institute of Surgery CSK WAM, Warsaw, Poland
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43
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Navez B, d'Udekem Y, Cambier E, Richir C, de Pierpont B, Guiot P. Laparoscopy for management of nontraumatic acute abdomen. World J Surg 1995; 19:382-6; discussion 387. [PMID: 7638993 DOI: 10.1007/bf00299164] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The diagnostic and therapeutic influence of laparoscopy has been studied in 255 patients presenting with nontraumatic acute abdominal pain. Laparoscopy provided a correct diagnosis in 93% (236 of 255) of the cases, the others requiring a laparotomy. An erroneous preoperative diagnosis was corrected by laparoscopy in 50 patients (20%), which called for a change of treatment in 25 patients (10%). Seventy-three percent (186 of 255) of acute abdominal conditions were treated exclusively by laparoscopy, 23% (58 of 255) by conventional surgery, and 4% (11 of 255) by laparoscopically assisted surgery. Mortality was 2% (5 of 247) and morbidity 11% (28 of 247). We conclude that laparoscopy is a valuable tool for the general surgeon facing a patient with an acute abdomen.
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Affiliation(s)
- B Navez
- Service de Chirurgie Générale, Digestive et Urologique, Hôpital St. Joseph, Gilly (Charleroi), Belgium
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Lacy AM, Balaguer C, Andrade E, García-Valdecasas JC, Grande L, Fuster J, Bosch J, Visa J. Laparoscopic cholecystectomy in cirrhotic patients. Indication or contradiction? Surg Endosc 1995; 9:407-8. [PMID: 7660263 DOI: 10.1007/bf00187160] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Liver cirrhosis is considered a contraindication to laparoscopic cholecystectomy for the moment. Here we are reporting on results in the surgical treatment of gallstone disease in cirrhotic patients by laparoscopic means. We reviewed the experience over the final period of time in 11 patients since the introduction of laparoscopic procedures in our unit. The index of conversion rate was 9.1% (1/11). The morbidity was nil. The average length of hospital stay was 1.8 days (1-6 days). We propose the use of laparoscopic cholecystectomy in gallstone disease in patients with liver cirrhosis as first-line surgical treatment.
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Affiliation(s)
- A M Lacy
- Department of Surgery, Hospital Clínic, University of Barcelona, Spain
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45
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Tucker JG, Ambroze WL, Orangio GR, Duncan TD, Mason EM, Lucas GW. Laparoscopically assisted bowel surgery. Analysis of 114 cases. Surg Endosc 1995; 9:297-300. [PMID: 7597602 DOI: 10.1007/bf00187772] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.
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Affiliation(s)
- J G Tucker
- Department of Surgery, Georgia Baptist Medical Center, Altanta 30312, USA
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46
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Cleary R, Venables CW, Watson J, Goodfellow J, Wright PD. Comparison of short term outcomes of open and laparoscopic cholecystectomy. Qual Health Care 1995; 4:13-7. [PMID: 10142030 PMCID: PMC1055260 DOI: 10.1136/qshc.4.1.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the three month outcome of open and laparoscopic cholecystectomy. DESIGN Prospective assessment of outcome for a series of patients encompassing the introduction of the laparoscopic technique. SETTING One teaching hospital. PATIENTS 269 patients admitted for open cholecystectomy between January 1989 and March 1992 and 122 admitted for laparoscopic cholecystectomy between January 1991 and March 1992. MAIN MEASURES Patients' reported symptoms and self assessed scores with the Nottingham health profile before operation and at three month follow up. Incidence of complications and adverse events after discharge. RESULTS Similar improvements in symptom rates and health scores were seen regardless of surgical technique. A lower rate of postoperative complications was seen in the patients given laparoscopic surgery (6/95(6%) v 45/235(19%)), and their mean length of stay was lower (4.5 v 9.8 days). Similar results were obtained when the analysis was restricted to a subset of fairly uncomplicated cases (patients aged 60 or less without other illnesses on admission who were not undergoing emergency or urgent surgery), which constituted a larger proportion of the group given laparoscopy (35/95(37%) v 40/235(17%)). Between these two groups no significant difference was seen in the frequency of relevant readmissions to hospital or visits to general practitioners or accident and emergency departments. CONCLUSION Ideally, a new surgical technique would be evaluated in a randomised trial. In the absence of such a trial, this observational study provides some evidence that the switch from open to laparoscopic cholecystectomy has brought benefits, particularly in terms of reduced length of stay in hospital. A range of clinical and patient derived indicators suggests that these gains have not been associated with a reduction in the quality of the outcome at three months.
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Martin IG, Dexter SP, Marton J, Gibson J, Asker J, Firullo A, McMahon MJ. Fundus-first laparoscopic cholecystectomy. Surg Endosc 1995; 9:203-6. [PMID: 7597594 DOI: 10.1007/bf00191967] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Removal of the gallbladder with commencement of dissection at the fundus is well recognized as a safe technique during difficult "open" cholecystectomy because it minimizes the risks of damage to the structures in or around Calot's triangle. We report here the routine employment of liver retractors and fundus-first dissection during laparoscopic cholecystectomy (LC) as an alternative to techniques previously described. Retraction of the liver and "fundus-first" dissection was used in 53 patients who underwent laparoscopic cholecytectomy. There were 16 male and 37 female patients. Seven were operations performed during an acute admission and 20 had moderate or severe adhesions involving the gallbladder. Thirteen patients had a preexisting abdominal incision. The procedure was successful in 52 patients (98%), but in one patient it was converted to open operation because of dense adhesions. Median duration of operation was 90 min (range 35-240 min). There was no mortality and two complications (persistent right upper quadrant pain for 2 weeks after operation and bile leakage from the gallbladder bed). The facility to retract the liver and carry out a fundus-first dissection extends techniques developed for "open" surgery into the laparoscopic arena. It offers the surgeon the safety and versatility during laparoscopic cholecystectomy that it confers during conventional open surgery.
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Affiliation(s)
- I G Martin
- Leeds Institute for Minimally Invasive Therapy, Division of Surgery, General Infirmary at Leeds, UK
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48
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Abstract
Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.
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Affiliation(s)
- F Bongard
- Harbor-UCLA Medical Center, UCLA School of Medicine, Torrance
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49
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Tyagi NS, Meredith MC, Lumb JC, Cacdac RG, Vanterpool CC, Rayls KR, Zerega WD, Silbergleit A. A new minimally invasive technique for cholecystectomy. Subxiphoid "minimal stress triangle": microceliotomy. Ann Surg 1994; 220:617-25. [PMID: 7979609 PMCID: PMC1234449 DOI: 10.1097/00000658-199411000-00004] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The authors devised a minimally invasive technique for cholecystectomy via microceliotomy that provides safety attainable with the open conventional approach and postoperative results comparable to laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA Laparoscopic cholecystectomy has evolved as a minimally invasive outpatient procedure. Patients can return rapidly to preoperative status with minimal postoperative morbidity and pain, and the small scar size is cosmetically desirable. Unfortunately, there are reports of serious intraoperative complications, including injury to blood vessels, bowel, and the bile ducts, caused by failure to identify structures properly. The conventional cholecystectomy technique currently is relegated to patients on whom the laparoscopic procedure cannot be performed. METHODS Cholecystectomy was performed through a 3-cm transverse high subxiphoid incision in the "minimal stress triangle." The location, anterior to Calot's triangle, was critical in providing a direct vertical view of the biliary ducts during dissection. Direct view cholecystectomy was performed using endoscopic instruments without pneumoperitoneum. Postoperative data were compared with both laparoscopic and open cholecystectomy results. RESULTS Using the microceliotomy technique in the ambulatory setting, cholecystectomy was performed successfully in 99.3% (N = 143) of cases. Biliary leakage beyond the third postoperative day was caused by failure of clips or obstruction to bile flow. The postoperative morbidity, acceptability of scar, and analgesic requirements compare favorably with other techniques. Microceliotomy is cost effective. Portal hypertension is a contraindication for this procedure. CONCLUSIONS The microceliotomy approach offers a viable, safe, and cost-effective alternative to the laparoscopic technique for cholecystectomy, especially when facilities for laparoscopy are not available or when the laparoscopic procedure cannot be performed.
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Affiliation(s)
- N S Tyagi
- St. Joseph Mercy Hospital, Pontiac, Michigan
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50
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Abstract
Laparoscopic cholecystectomy is a relatively new surgical procedure which is enjoying ever-increasing popularity and presenting new anesthetic challenges. The advantages of shorter hospital stay and more rapid return to normal activities are combined with less pain associated with the small limited incisions and less postoperative ileus compared with the traditional open cholecystectomy. The efficacy of laparoscopic appendectomy and hemicolectomy has been recently evaluated. However, there have been no prospective randomized studies to date comparing laparoscopic with traditional laparotomy techniques. The physiological effects of prolonged pneumoperitoneum and the longer duration of surgery with the laparoscopic techniques are of concern. The application of laparoscopic inguinal hernia repair may be limited because, unlike traditional surgical hepair, general anesthesia is required and concerns have been expressed about the duration of surgery and the possibility of hernia recurrence. Notwithstanding case reports and series describing successful diaphragmatic and hiatus hernia repair using a laparoscopic surgical technique, the frequently encountered complications of cervical surgical emphysema, pneumothorax, and pneumomediastinum, attributed to passage of insufflating gas through weak points or defects in the diaphragm, must be of major concern. Anesthesiologists must maintain a high index of suspicion for these potential complication and must undertake appropriate monitoring. If there is clinical evidence of a tension pneumothorax, immediate chest tube decompression is indicated. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiological changes associated with patient positioning and pneumoperitoneum creation. The choice of anesthetic technique for upper abdominal laparoscopic procedures is most frequently limited to general anesthesia. Controlled ventilation avoids hypercarbia, and an anesthetic technique incorporating antiemetics and nonsteroidal anti-inflammatory agents has reduced postoperative nausea and vomiting following laparoscopic cholecystectomy. The use of nitrous oxide during laparoscopic procedures remains controversial. Laparoscopic cholecystectomy is a major advance in the management of patients with symptomatic gall-bladder disease. However, in the present era of cost containment, older and sicker patients may present for this procedure on the day of surgery without adequate preoperative evaluation. Anesthesiologists should thus be prepared to recommend deflation of the pneumoperitoneum and possibly conversion to an open procedure if hemodynamic, oxygenation, or ventilation difficulties arise during the procedure.
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Affiliation(s)
- A J Cunningham
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Dublin
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